Application Form

Certificate in Couple Counselling – CCC-2 (M)

Application Form

Name: (Mr/Miss/Mrs/Dr) ________________________________________________________

Address(Residence):__________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Occupation/Designation:____________________________________________________

Tel:(O)_________________________________(Res.)___________________________

E-mail: ___________________________________H/P: _________________________

Employer / Agency:_______________________________________________________________

Employer’s Address: ________________________________________________________________________

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Academic Qualification: 1.________________________Year graduated:___________

                                       2._________________________Year graduated:___________

Present job responsibilities/description/nature of work

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Brief description of previous relevant experience pertaining to counselling:

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Reasons for enrolling:

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Deadline for registration: 4 July 2018.  To register either: a. e-mail your completed registration form & pay 1^st Installment course fee of Rm 2,250.00 through online banking to Tan Leh Ou  Maybank a/c No: 1142-3612-9050 and alert recipient by e-mail/whatsapp after payment @ warrentan2@gmail.com or b. post your completed registration form together with your  M’sian cheque in favor of Tan Leh Ou for Rm 2,250.00 to:    

                                                             Choice Makers Consultancy                                                                

                                                                  136 Rivervale Street

                                                                  #12-742

                                                                  Singapore 540742

                                                                  Mobile/Whatsapp: 65-9631-3814 

                                                                  E-mail: warrentan2@gmail.com

                                                                  

Signature       /        Date